Heart failure (HF) is a major health problem that has been described as a chronic disease epidemic. The incidence is greatest among those over 65 who typically experience compromised biopsychosocial functioning, frequently suffer from co-morbidities and age-related changes, and require complex treatment regimens and lifestyle alterations. New York Heart Association (NYHA) Class III and IV HF patients are the most severely ill often experiencing persistent deteriorating symptomatology leading to diminished quality of life, high hospital readmission rates, and frequent admissions to home healthcare costing Medicare $21.4 billion annually, of which $2.4 million is associated with home healthcare. Strategies are urgently needed in the financially constrained home healthcare industry that meet patient and family needs and are clinically effective and cost efficient. The purpose of this prospective randomized clinical trial is to pilot test a comprehensive telephone-mediated intervention delivered by home healthcare staff nurses to older adults in their homes and designed to improve selected outcomes of care for patients with NYHA Class III and IV HF. Selected outcomes will be compared between two groups of patients. The control group (N=71) will receive usual care based on an agency derived HF clinical pathway. The intervention group will receive usual care supplemented by a comprehensive telephone-mediated intervention designed to provide: a) a consistent and sustained nurse-initiated standardized schedule of telephone interactions; b) weight scales for patient self-monitoring; c) increased patient self-reports of symptom data; d) additional dedicated time for delivery of three nursing actions known to affect HF outcomes: vigilant monitoring of pertinent symptoms, facilitation of learning, and provision of emotional support. The intervention group nurses (RNs) will be thoroughly trained and follow a uniform protocol throughout the study including a standardized telephone script. The intervention was designed by the researchers and is guided by the Quality-Caring Model. (c) Subjects will be assigned to groups in an odd/even scheme. Patient outcomes include: quality of life, hospital readmissions, and satisfaction with care. Resource consumption, including utilization and costs, and intermediate HF pathway goals met will be compared. Data analysis included independent samples T-tests, Chi square analysis, ANCOVA, and regression analysis for quantitative variables and content analysis for qualitative data. Data will be stratified to detect differences in minority or gender sub-groups. Findings will contribute to optimal care of older adults with NYHA Class III and IV HF who are living at home and receiving home healthcare services and provide the basis for further study. Finding will also provide direction for administrators and policy-makers in designing cost effective delivery systems.